Ask the Experts - Immunization Action Coalition

1 Ask the When should influenza vaccine be given? You can begin administering vaccine as soon as it of at least two doses of trivalent or quadrivalent influenza vaccine before July 1, 2017, or 3) if their Experts becomes available. Optimally, vaccination should occur before onset of influenza activity in the com- munity. Healthcare providers should offer vaccina- vaccination history is unknown. The two doses need not have been received during the same season or consecutive seasons. IAC's handout titled Guide The Immunization Action Coalition extends thanks tion by the end of October, if possible, and vaccina- for Determining the Number of Doses of Influenza to our Experts , medical officers Andrew T. Kroger, tion activity should continue through the fall and Vaccine to Give to Children Ages 6 Months MD, MPH; Candice L. Robinson, MD, MPH; winter months, as long as influenza virus is circu- Through 8 Years provides guidance on this issue; it Raymond A.

2 Strikas, MD, MPH, FACP, FIDSA; lating in the community. Early vaccination of is available at and nurse educators Donna L. Weaver, RN, MN, children younger than age 9 years who need 2 doses and JoEllen Wolicki, BSN, RN, all with the National of vaccine can be helpful in assuring routine second Can a child 6 through 35 months of age who Center for Immunization and Respiratory Diseases doses are given before the influenza season begins. needs 2 doses of influenza vaccine this season receive one each of Fluzone and FluLaval at the Centers for Disease Control and Prevention When administering influenza vaccine, vaccine? (CDC). is giving patients a VIS mandatory or Yes. Both Fluzone ( mL dose) and FluLaval is it only recommended ? ( mL dose) are approved by the FDA for use in Influenza vaccines Giving patients an influenza Vaccine Information children 6 through 35 months of age.

3 Statement (VIS) is mandatory under the National What's new in the 2017 18 influenza vaccine Childhood Vaccine Injury Act of 1986. The VIS If a child receives Fluzone vaccine ( mL). recommendations? must be given to all adults as well as to parents or at age 34 or 35 months for the first time and The 2017 18 ACIP influenza vaccine recommen- guardians of children prior to vaccination. Two then returns for the second dose at age 37. dations were published on August 25, 2017, and are VISs are available, one for LAIV (although LAIV months, should we give another mL dose available online at is not recommended to be used during the 2017 18 of Fluzone or should we give the mL dose 66/rr/ The new guidance season) and one for inactivated influenza vaccine that is indicated for age 3 and older? Describes the vaccine composition for this season (IIV). Each can be found at The child should always receive the dose appropri- (a change in the A/H1N1 component); vis along with many translations.

4 The influenza ate for his or her age at the time of the clinic visit;. Discusses recent FDA licensure and labelling VIS has been modified so that it does not need to at age 37 months that would be mL. changes including be replaced each year. The 2015 16 influenza VIS. approval of Afluria Quadrivalent (Seqirus) and A 1-year-old was inadvertently given a (used for the past two years) should be used during Flublok Quadrivalent (Protein Sciences); mL dose of FluLaval rather than the recom- the 2017 18 season. expansion of the age indication for FluLaval mended mL dose. What should we do? Quadrivalent (GSK) to age 6 months and older Which influenza vaccines can we give to If the error is discovered while the child is still in (previously licensed for people 3 years and children? the office, you can administer the other half of older); Among the injectable inactivated influenza vac- the FluLaval dose.

5 If the error is discovered later, expansion of the age indication for Afluria cines, both Fluzone (Sanofi Pasteur) and FluLaval the dose should not be counted, and then the child (Seqirus) to include persons 5 years and older are approved by the FDA for use in children ages should be recalled to the office and given a full (previously recommended for persons 9 years 6 through 35 months. There are several inactivated age-appropriate repeat dose, either a mL dose and older); and influenza vaccines that can be given to children age of FluLaval or a mL dose of Fluzone. Recommends that live attenuated influenza vac- 3 years or older. Is influenza vaccine recommended cine (LAIV, FluMist; AstraZeneca) not be used Please provide details about the use for pregnant women? during the 2017 18 season. of FluLaval influenza vaccine in children Yes. It is especially important to vaccinate pregnant Which influenza vaccines will be available younger than 3 years.

6 Women because of their increased risk for influ- during the 2017 18 influenza season? On November 18, 2016, the FDA approved an enza-related complications. An increased risk of Multiple manufacturers are producing influenza extension of the age range of quadrivalent FluLaval severe influenza infection was also observed in vaccine for the market for the 2017 18 season. IIV to include children 6 through 35 months of age. postpartum women (those who delivered within Inactivated vaccines will be produced using egg- FluLaval was previously approved for people 3 the previous 2 weeks) during the 2009 10 H1N1. based, cell culture based, and recombinant tech- years of age and older. The approval of the extended pandemic. Vaccination can occur in any trimester, nologies. Some of the inactivated influenza vac- age range for FluLaval was based on a study show- including the first.

7 Only inactivated vaccine should cines will be quadrivalent (containing four strains ing an equivalent ( non-inferior ) response com- be given to pregnant women. of influenza virus) rather than trivalent (three pared to children who received the Fluzone pediatric I heard that a recent study suggested strains). LAIV may be available but is not recom- dosage. The vaccine is supplied for this indication an increase in miscarriage among women mended for use during the 2017 18 season. A in manufacturer-filled syringes and multi-dose who received inactivated influenza vaccine. complete listing of influenza vaccine products is vials. The dosage approved for children 6 through Please provide details. available from the Immunization Action Coalition 35 months of age is mL the same dosage as A CDC-funded study found that women who had (IAC) at for people 3 years of age and older.

8 Been vaccinated early in pregnancy with an influ- Who is recommended to be vaccinated Which children younger than age 9 years enza vaccine containing the pandemic H1N1. against influenza? will need 2 doses of influenza vaccine (H1N1pdm09) component and who also had been ACIP recommends annual vaccination for all in this influenza season? vaccinated the prior season with an H1N1pdm09- people ages 6 months and older who do not have Children age 6 months through 8 years should containing influenza vaccine had an increased risk a contraindication to the vaccine. receive a second dose 4 weeks or more after the of spontaneous abortion (miscarriage) in the 28. first dose 1) if they are receiving influenza vaccine for the first time, 2) if they did not receive a total Ask the Experts .. continued on page 5 . 4 NEEDLE TIPS November 2017 Immunization Action Coalition (651) 647-9009 IAC's Ask the Experts team from the Centers for Disease Control and Prevention Should staff at drive-through influenza vaccination clinics encourage drivers to park and wait for 15 minutes after vaccination to make sure they don't have a syncopal (fainting) episode?

9 Yes. Syncope has been reported following vaccina- tion. It is prudent for all persons to be observed for syncope for at least 15 minutes after vaccination. When removing both pediatric ( mL) and Andrew T. Kroger, Candice L. Robinson, Raymond A. Strikas, Donna L. Weaver, JoEllen Wolicki adult ( mL) doses from a multi-dose vial of MD, MPH MD, MPH MD, MPH, FACP, RN, MN BSN, RN. Fluzone, we can get more than 10 doses from FIDSA. the mL vial. Can we continue to remove doses from the vial until it is empty? Ask the from page 4 Fluzone (N Engl J Med 2014; 371:635 45), ACIP No. Only the number of doses indicated in the has not stated a preference for this vaccine for manufacturer's package insert should be withdrawn days after vaccination. This study does not quantify people age 65 years and older. from the vial. For a mL vial of Fluzone this is the risk of miscarriage and does not prove that 10 doses.

10 After the maximum number of doses has influenza vaccine was the cause of the miscarriage. May Fluzone High-Dose or Fluad be adminis- been withdrawn, the vial should be discarded, even Earlier studies have not found a link between tered to patients younger than age 65 years? if there is vaccine remaining in the vial and the influenza vaccination and miscarriage. There is an No. Fluzone High-Dose and Fluad are licensed expiration date has not been reached. ongoing investigation to study this issue further only for people age 65 years and older and are not among women who were pregnant and eligible to recommended for younger people. We inadvertently administered intradermal receive influenza vaccine during the 2012 13 influenza vaccine to a patient who is outside What is the latest ACIP guidance on the recommended age range of 18 through 64. through 2014 15 influenza seasons.